The evolution of TQIP Best Practices for Massive Transfusion Bryan A Cotton, MD, MPH Associate Professor of Surgery Department of Surgery and The Center for Translational Injury Research University of Texas Health Science Center Houston, Texas
The evolution of TQIP Best Practices for
Massive Transfusion
Bryan A Cotton, MD, MPH
Associate Professor of Surgery
Department of Surgery and
The Center for Translational Injury Research
University of Texas Health Science Center
Houston, Texas
Background
• Hemorrhage: most common cause of death
within the first hour of arrival.
• >80% of deaths in the OR and nearly 50% of
deaths in 1st 24 hours due to hemorrhage.
• While only 3% of civilian traumas will receive
a massive transfusion (MT), these patients
consume 70% of all trauma blood transfused.
Kauvar DS et al, J Trauma 2006
Sauaia A et al, J Trauma 1995
Como JJ et al, Transfusion 2004
Background
• MT scenarios are unplanned, require
processing/delivery of large amounts of
products rapidly in a sustained fashion .
• Significant pre-planning and coordination
between blood bank, ER, OR and Trauma.
• TQIP set out to identify necessary parts and
processes of an MTP and address key issues
involved in their development.
Cotton BA et al, J Trauma 2008
O’Keeffee T et al, J Trauma 2008
Why develop a MTP? • Protocolization of the process is associated
with decreased mortality, reduction in overall
transfusions and less MOF/ARDS.
• MTP are associated with reduced times to
first products available and decrease in blood
product wastage.
• These findings are independent of the ratio fo
plasma: RBC chosen.
Cotton BA et al, J Trauma 2009
Riskin DJ et al, JACS 2009
Gunter O et al, J Trauma 2009
Reduce transfusions…reduce
exposure… reduce complications
The protocol • Should be a written document, accessible to
all, and adopted by the center.
• Anyone who “touches” the MTP should be
involved with development and oversight.
• Provide for ratio based blood products,
empirically delivered.
• Standardization of coagulation assessment,
plans to treat acidosis, hypothermia, hypoCa+.
Trauma Surgeon calls BB to activate MTP
Surgeon provides BB with Stat name, gender,
approximate age, & O.R. number
BB calls OR to notify team that first round
MTP ready
BB calls the OR within 10-15 minutes to:
1) Notify team that next round of TEP ready
2) Ask team if MTP is to continue
MTP discontinued & unused products
returned to BB
Unless specified, BB releases prepared box
and ceases preparation of future boxes
BB begins preparation of next
round of products
First box prepared
and released:
6 U RBC
6 U plasma
1 apheresis platelet
Tech retrieves
products &
brings to O.R.
If “YES”
Type & screen
sent to BB
If “NO”
Next box prepared
and released:
6 U RBC
6U plasma
1 apheresis platelet
Tech retrieves
products &
brings to O.R. Surgeon notifies BB & stops MTP if:
1) hemostasis achieved,
2) case is completed, or
3) patient expires
Predicting need for MTP
• Predicting the need for MT is difficult.
• Mortality is improved with rapid implementation
of appropriate MT guidelines but complications
are increased if patients have unnecessary
exposure to blood products.
• Prediction tools have been developed for both
military and civilian trauma patients, with
specificities that range between 80% and 90%.
Available scoring systems
ABC Score
• Four (4) dichotomous components available during the “A-B-C’s”
• The presence of any one component contributes one point to the total score (range 0-4)
• Parameters: Penetrating MOI (0=no, 1=yes), ED SBP ≤ 90mmHg (0=no, 1=yes), ED HR ≥120 bpm (0=no, 1=yes), (+) FAST (0=no, 1=yes)
ABC vs. McLaughlin vs. TASH
J Trauma 2010
Activation of the MTP
• ABC over triage rate is high (PPV 50-55%)
• Under-triage rate <5% (NPV 95-97%).
• You can always send the cooler back, but you can’t make it quicker when you’re wrong.
• Other scores have been developed and all include the presence of severe tissue injury and hemorrhagic shock as important risk factors
UTHSC-Houston and the TMC
39
Trauma bay, OR, and IR
• Universal RBC (O-/+) and thawed AB plasma
immediately available, ideally stored in ED.
• Centers using thawed plasma early in resus
have seen reductions in blood product use.
• If unable to provide adequate stores of AB
plasma, low (anti-B) titer A plasma may be
utilized (or liquid plasma).
Trauma bay, OR, and IR
• To avoid “popping the clot,” DCR principles
suggest RBC/plasma be delivered by rapid
infuser/warmer.
• Initial rate of transfusion should restore
perfusion but allow for permissive hypotension
until operation to stop the bleeding has begun.
• Platelets and cryoprecipitate should not be
administered through a blood warmer.
Goals of early resuscitation in
Trauma bay, OR, and IR • Transfuse universal products in a ratio between
1:1 and 1:2 (plasma to RBC) at 100 mL/min.
• Transfuse one bag of platelets/ 6 units RBC.
• Products should be automatically sent by BB
within 15 minutes of MTP activation.
• Subsequent coolers should be delivered at 15
minute intervals until MTP terminated.
Goals of early resuscitation in
Trauma bay, OR, and IR
• In OR/IR, rapid delivery and transfusion should
continue (at set ratios) and at a rate to keep the
patient euvolemic while actively bleeding.
• Once major bleeding controlled and transfusion
rate slowed, appropriate to switch to lab or point
of care (POC)-based transfusion.
Radwan ZA et al. JAMA Surg
Zielinski MD et al. J Trauma Acute Care Surg
Armand R and Hess JR. Transfus Med Rev. 2003
•
ICU resuscitation
• MT=ICU admission
• ICU team should anticipate arrival of these
patients with the necessary equipment and
personnel to care for these patients.
• However, ongoing bleeding and RAPID
transfusion should return to OR
• Priorities: correct coagulopathy and associated
issues (hypothermia, acidosis, hypocalcemia)
ICU resuscitation
• ICU driven algorithm should be optimized to use
blood components for goal directed therapy.
• Hgb 8-10 g/dL (rheologic, facilitate clotting)
• Upon arrival, baseline labs, repeat frequently
until defects corrected (coags, TEG, iCa, abg)
• Once results available, goal directed resus
Royston D et al. Br J Anaesth. 2001
Holcomb JB et al. Ann Surg 2012
Ak K et al. J Card Surg, 2009
Transfusion Services
• Designated trauma centers should have on-site
Transfusion Service, operating 24/7, with SOP
for immediate, continuous delivery of products.
• Timely, precise communication between trauma
team, ED, OR, anesthesia and BB is critical.
• Most efficient way to immediately provide
products is with refrigerator in resuscitation bay.
• Rapid delivery of coolers from BB is best
accomplished through a dedicated runner.
Dutton RP et al. J Trauma 2005
Armand R and Hess JR. Transfus Med Rev 2003
Quillen K et al Transfusion 2011
Transfusion Services • Liquid or thawed plasma immediately available.
• AB ideal universal plasma, but only 4% donors.
• However, 40% donors A, many are low anti-B
titers; can be safely given to almost everyone.
• Switch to group specific plasma ASAP (10 min).
• Upon termination of MTP, PROMPT return of all
remaining blood products and coolers to BB.
End-points of transfusion
• Criteria for stopping MTP should include both
anatomic (control of bleeding) and physiologic
criteria (normalizing hemodynamic status).
• Decision to stop should be made by surgeon
and anesthesiologist, if still in OR, or the
intensivist/ trauma surgeon if in the ICU.
• Specific lab endpoints used to guide further
resus should be based on data and clinical
experience of those caring for the patient.
Pezold et al Sugery 2011
Reviewing your MTP
• You have to live to have a complication!
• Review hemorrhage/transfusion complications
• Review availability and management of blood
products during MTP.
• Review MTP cases with the following
complications: coagulopathy on ICU arrival,
thrombotic cx, ARDS, TACO/TRALI, death
Reviewing your MTP
• Performance indicators for the process of
massive transfusion should include:
* Time from calling MTP to 1st unit RBC
* Time from calling MTP to 1st unit plasma
* Adherence to pre-determined ratios
* Informing BB when MTP terminated
* Wastage/mishandling blood products
Conclusions
• Development and design must be multi-D
• Immediate availability of products
• Ratios of plasma and platelets matter
• Protocolization of the process matters
• Continuous PI/QI process is essential
The evolution of TQIP Best Practices for
Massive Transfusion
Bryan A Cotton, MD, MPH
Associate Professor of Surgery
Department of Surgery and
The Center for Translational Injury Research
University of Texas Health Science Center
Houston, Texas